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Kidney Week

Abstract: PO2095

A Tale of Survival: COVID-19, Disseminated Cryptococcus, and Cytomegalovirus Disease in an ABO-Incompatible Kidney Transplant Recipient

Session Information

Category: Transplantation

  • 1902 Transplantation: Clinical

Authors

  • Jain, Rishabh Kumar, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
  • Thaduri, Sudhir R., The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
  • Kumar, Vineeta, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
Introduction

We present a rare case of Collapsing Focal Segmental Glomerulosclerosis (FSGS) in Covid-19 (COVAN), disseminated Cryptococcus and CMV infection in a kidney transplant recipient with dialysis dependent acute kidney injury and successful renal and critical illness recovery.

Case Description

63yo black male with an ABO incompatible kidney transplant 8yrs ago, baseline creatinine (Cr) of 1.4 mg/dl with acute Covid-19 infection with presenting Cr of 5.5 mg/dl and nephrotic range proteinuria (5.9gm/gm). Started hemodialysis on day 21 of the acute illness. Normal imaging, stable anti-ABO titers and transplant kidney biopsy with collapsing FSGS and ATN. Blood cultures ordered for persistent fevers were positive for Cryptococcus neoformis. Biopsy of painful indurated skin of the left flank revealed variably sized yeast forms within the dermis consistent with cutaneous Cryptococcus. Treated with amphotericin B/flucytosine followed by fluconazole with clearance of fungemia, resolution of fever and improvement of skin lesions. Immunosuppression was continued with reduced dose of tacrolimus and prednisone 10mg/day. Antimetabolite was discontinued.Persistent weakness and diarrhea lead to testing for CMV with PCR at 51,000copies/ml, treated with IV ganciclovir with complete resolution of symptoms. Discharged home on maintenance dialysis with valganciclovir and fluconazole prophylaxis.
He returned on day 70 of illness with a Cr of 1.2 mg/dl, a 24hour urine collection with a creatinine clearance of 28 ml/min and 2gms of proteinuria. Dialysis was discontinued due to renal recovery.
At last clinic follow up, day 100 from diagnoses, Cr remains stable at 1.7 mg/dl off dialysis.

Discussion

Immune dysregulation in the setting of acute Covid-19 infection coupled with long term immunosuppression may have contributed to multiple opportunistic infections. Optimal approach for immunosuppression in KTRs with acute Covid-19 infection is still evolving. Our patient was successfully treated without stopping all immunosuppression. Our case underscores importance of having low threshold to test for various opportunistic infections even in the setting of active Covid-19 infection. While data on COVAN in KTRs is limited, our case shows potential for renal recovery even in a high immunologic risk kidney transplant recipient.